Commercial Determinants and the Test of Better Outcomes
The Center for Global Health Accountability plans to develop a programme of work on the commercial determinants of health in 2027, along the lines outlined in this paper.
If a company develops a product that reduces disease, should public-health organizations welcome it even when the company profits?
The answer should be straightforward: assess the evidence, compare the alternatives and establish whether health improves. Yet commercial innovation creates a difficult test for organizations whose missions, reputations and fundraising have developed around opposition to particular industries.
CGHA’s starting principle is measuring outcomes, not intentions. That principle applies equally to companies claiming to improve health and to organizations campaigning against them.
A framework that must recognize improvement
The commercial determinants of health describe how business activities affect health. Those effects can be harmful: unsafe products, misleading promotion and concealed evidence deserve scrutiny. They can also be beneficial. The World Health Organization explicitly recognizes both possibilities, identifying medicines, safer products and food reformulation among the positive contributions businesses can make.
The important question is how this framework operates in practice. Does it distinguish between harmful conduct and beneficial innovation? Can companies change sufficiently to earn recognition from their critics? And do public-health organizations explain what evidence would lead them to revise their positions?
The proposed research would test whether some organizations become so committed to opposing an industry that they struggle to recognize health improvements delivered through its transformation. This is a proposition to investigate through observable conduct, rather than an assumption about private motives.
The revealing test: what happens when products change?
Nicotine provides an obvious starting point. An organization seeking to reduce smoking-related disease should assess alternatives according to their risks and their effects on smoking. That assessment must consider complete switching, continued cigarette use, youth uptake, dependence and uncertainty about longer-term outcomes.
Neither a manufacturer’s promise nor its history settles those questions. The revealing issue is whether critics distinguish between products and update their judgments as evidence develops. If every improvement is dismissed because the manufacturer remains commercially successful, opposition risks becoming detached from its original health objective.
Food and drink raise comparable questions. Reformulation, smaller portions and lower-sugar alternatives should be assessed against what people would otherwise consume. An improved product need not be ideal to represent progress. Equally, a modest reformulation does not establish that a company’s whole portfolio or marketing strategy benefits health.
There are useful counterexamples to any claim that nongovernmental organizations uniformly reject commercial improvement. The Access to Nutrition initiative, known as ATNi, is a nonprofit organization that assesses food and beverage companies and seeks to encourage healthier products and markets. Its approach combines scrutiny of company performance with efforts to change commercial incentives. Such approaches belong in the comparison, alongside organizations that favour exclusion or confrontation.
Low- and no-alcohol drinks present another test. The relevant questions include whether they replace alcoholic drinks, attract new consumers or provide additional opportunities to promote established brands. Their commercial origin cannot answer those empirical questions.
Obesity medicines make the trade-offs explicit
Obesity medicines illustrate why public-health analysis must weigh benefits against burdens.
The SELECT clinical trial of semaglutide enrolled people with established cardiovascular disease and overweight or obesity, without diabetes. Major cardiovascular events occurred in 6.5% of the treatment group and 8.0% of the placebo group over a mean follow-up of approximately 40 months. Discontinuation because of adverse events was also higher: 16.6% versus 8.2%.
These outcomes cannot simply be subtracted from each other. Their severity, duration and implications differ. The results also concern a defined patient population, rather than everyone who might seek weight-loss treatment.
A credible assessment can acknowledge therapeutic benefits while questioning price, access, prescribing or promotion. It should also recognize that expected side effects remain relevant to patients. The test is whether benefits and harms receive proportionate attention, including the consequences of leaving disease untreated.
The connection to lawfare
Commercial incentives also operate among those challenging manufacturers.
CGHA’s lawfare series examines several mechanisms through which disputes can shape policy. When Process Becomes Punishment addresses the burdens imposed by legal proceedings; When Evidence Becomes Authority examines the movement of scientific claims into policy and litigation. Beyond Deep Pockets extends scrutiny to pressures on participants beyond corporate defendants.
The institutional questions developed in Silence in Geneva and the campaign incentives considered in When the Campaign Becomes the Cause connect directly to the commercial determinants debate.
Plaintiffs’ firms, expert witnesses and litigation funders can have financial interests in health controversies. Advocacy organizations may receive support from legal actors. For example, the Asbestos Disease Awareness Organization’s 2026 conference lists five law firms as sponsors and explicitly states that the organization makes no legal referrals. The public-interest legal organization Public Justice reports receiving nearly 150 court-approved cy pres awards—distributions made when settlement funds cannot practicably be fully distributed to class members.
These relationships do not establish misconduct or prove that funding determines an organization’s position. Litigation can expose wrongdoing and compensate injured people. But its financial incentives deserve examination alongside those of manufacturers.
Talc and glyphosate would be useful supplementary cases for investigating these relationships. Establishing that financial interests exist is only the beginning; demonstrating that they influenced scientific claims or campaign decisions requires further evidence.
An achievable standard of accountability
The planned 2027 programme would compare organizations’ statements before and after significant changes in evidence or products. It would examine whether they recognize relative risk, acknowledge benefits, correct errors and specify conditions under which their position would change.
It would also examine legitimate reasons for rejecting commercial initiatives. A safer product might expand consumption, displace something safer or be marketed deceptively. Rejection alone cannot establish ideological hostility.
The same scrutiny applies to companies. An improved product cannot excuse concealment, exaggerated claims or harmful practices elsewhere. Any corporate support for CGHA’s research should be disclosed, with researchers retaining control over methods, findings and publication.
The practical standard is demanding but achievable: evaluate products against realistic alternatives, make trade-offs explicit and revise judgments when the evidence warrants it.
What would an industry have to do for its public-health critics to acknowledge that it had improved health?
Where the answer identifies measurable improvements, there is a basis for accountability. Where no achievable improvement could qualify, the campaign’s relationship to its stated health objective deserves closer examination.
